Page 190 - Read Online

Page 4 of 13 Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70

A B C

D E

Figure 1. A, B: pre-op and Post-op photo of a patient with lymphoedema of the right leg; C, D: supraclavicular flap harvested and
anastomosed to the posterior tibial artery; E: lymphovascular anastomosis done in the right foot

symptomatic improvement), since the lower limb is dependent and associated with higher venous
pressures. The efficacy of LVA treatment is dependent more on the severity of the lymphoedema than to
the duration of the lymphedema, with later stage lymphedema being less responsive.

VLNT
VLNT is a means to treat lymphoedema by replenishing the missing lymph nodes of the affected extremity
by harvesting healthy vascularised lymph nodes from one area of the body and transplanting them to the
[22]
affected extremity with the help of microsurgery .

In early cases of lymphoedema, LVA is possible. However, in late cases, the limb is fibrotic and sclerosed,
and VLNT is a physiological means to improve lymphoedema. The presence of significant backflow with
few or no functioning lymphatic vessels on imaging using ICG, lymphography, lymphoscintigraphy or
[23]
MRL suggests that VLNT may be indicated . VLNT can be combined with LVA in certain cases if some
good lymphatic channels are available, to give a better outcome [Figure 1A-E].

Several theories regarding how VLNT works have been postulated, since the precise mechanism of action
[24]
of VLNT is incompletely understood. Honkonen et al. used a swine model to propose that VLNT acts
like a “lymphatic wick” between the proximal and distal lymphatic vessels at the recipient site. This theory
seems to be attractive, especially in the early stages when functional lymphatic channels are retained in both
the proximal and distal segment. It is also believed that lymphatic connections are established between the
vascularised lymph node flaps and the surrounding tissues. Saaristo proposed that high levels of vascular
endothelial growth factor C is produced by the transferred lymph nodes which induces lymphangiogenesis
[25]
and facilitates recanalisation of the lymphatic vessels between the recipient and transferred lymph nodes .
These theories probably explain why VLNTs are transferred to proximal levels in the limbs. This is best
illustrated by the case of using the deep inferior epigastric perforator (DIEP) flap along with the lymph
nodes in the groin to treat post-mastectomy lymphoedema. Besides, the release of scar tissue in the axilla
can result in early improvement by releasing the pressure on the axillary vein which will reduce capillary
filtration. There is also abundant soft tissue to allow easy closure at the donor site, and the scar is well